Diagnosis & Treatment Plan

This document records the four examinations — inspection, auscultation/olfaction, inquiry, and palpation — synthesises a TCM pattern differentiation, and lays out the treatment principle, modalities, and course plan for the patient.

Patient & Visit

Patient name:

Visit date:

Practitioner:

Visit type: [New consultation / Follow-up visit]

Inspection

Complexion:

[Practitioner notes complexion — e.g. Pale / Yellow / Red / Dark with TCM interpretation]

Physical build:

[Practitioner notes build — Thin/frail / Robust / Overweight (damp build)]

Demeanour and spirit:

Eyes / lips / skin observations:

Auscultation & Olfaction

Voice:

[Practitioner notes voice — Weak/low (deficiency) or Loud/forceful (excess)]

Cough characteristic:

[Practitioner notes cough — Dry / Productive / Wheezing — and any breath or body odour observations]

Notes:

Inquiry

Refer back to the intake form. Record updates, new symptoms, or clarifications gathered today:

Pulse Diagnosis

Qualities to consider: floating / sinking / slippery / wiry / thin / rapid / slow / weak / forceful.

Overall pulse pattern interpretation:

Tongue Inspection

Body colour:

[Practitioner notes — Pale / Pink / Red / Purple / Dark]

Body shape:

[Practitioner notes — Swollen / Thin / Tooth-marked / Cracked]

Coating colour:

[Practitioner notes — White / Yellow / Grey / Black]

Coating thickness:

[Practitioner notes — Thin / Thick / Peeled or patchy]

Coating texture:

[Practitioner notes — Dry / Moist / Greasy or sticky]

Tongue notes (location of features, sublingual veins, etc.):

Pattern Differentiation

Primary pattern (e.g. "Liver Qi stagnation with Spleen deficiency"):

Secondary pattern, if any:

Pathogenic factors:

[Practitioner notes applicable factors — Wind / Cold / Heat / Dampness / Dryness / Fire]

Root cause analysis and the relationship between root and branch:

Treatment Principle

e.g. "Soothe the Liver, strengthen the Spleen, resolve dampness".

Recommended Modalities

[Practitioner selects modalities — Acupuncture / Cupping / Tuina / Gua sha / Moxibustion / Electroacupuncture / Herbal formula / External application (poultice or wash) / Dietary therapy]

Suggested Acupuncture Points

List points with rationale (e.g. LV3 Taichong — soothe Liver, move Qi):

Herbal Formula Direction

Base formula name (e.g. Jiawei Xiaoyao San (modified)):

Modifications and rationale:

Course Plan

Sessions per week: [1 / 2 / 3 sessions per week — practitioner selects]

Total sessions planned:

Expected timeframe:

Review checkpoint (after how many sessions):

Lifestyle & Dietary Advice

Foods to favour / avoid, sleep guidance, exercise (e.g. tai chi, qi gong, walking), and emotional self-care:

Expected Outcomes

Realistic goals at the review checkpoint and at course completion:

Possible Reactions / Caution

e.g. mild bruising from cupping, transient soreness after needling, possible herb side effects, healing crisis.

Practitioner Sign-Off

Practitioner name:

Signature date:

Patient has reviewed the plan and agrees to proceed

This plan will be re-evaluated at the review checkpoint and adjusted to the body’s response.

Authorized representative — printed name:

Signed date:

Signer — printed name:

Signed date: